title: Microscopic anterior foraminal decompression combined with anterior lumbar interbody fusion.
abstract: BACKGROUND
  Anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) provides successful surgical outcomes to isthmic spondylolisthesis patients with indirect decompression through foraminal volume expansion. However, indirect decompression through ALIF followed by PPF may not obtain a successful surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or foraminal sequestrated disc herniation. Thus far, there has been no report of foraminal decompression through anterior direct access in the lumbar spine.
  
  
  OBJECTIVE
  This study aims to describe the new surgical technique of microscopic anterior foraminal decompression and to analyze the clinical outcomes and radiologic results of the microscopic anterior decompression during ALIF followed by PPF.
  
  
  METHODS
  We conducted a multisurgeon, retrospective, clinical series from a single institution.
  
  
  METHODS
  This study was carried out from March 2007 to July 2010 and included 40 consecutive patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by posterior osteophyte or foraminal sequestrated disc herniation undergoing microscopic anterior foraminal decompression during ALIF followed by PPF.
  
  
  METHODS
  The visual analog scales (VAS) of back and leg pain and the Oswestry disability index were measured preoperatively and at the last follow-up.
  
  
  METHODS
  Postoperative computed tomography and magnetic resonance imaging measured whether decompression of neural structure had been made and morphometric change of the foramen and the amount of resected bone. Moreover, segmental lordosis, whole lumbar lordosis, disc height, and degree of listhesis were measured through X-ray examination before the operation and at the last follow-up; we also verified whether fusion had been achieved.
  
  
  RESULTS
  Successful decompression was confirmed in both patients with foraminal stenosis caused by posterior osteophyte and those with foraminal sequestrated disc herniation. Clinically, compared with before the surgery, the VAS (leg and back) and the Oswestry disability index significantly decreased at the last follow-up (p=.000). With regard to radiology, at the last follow-up all patients had bone fusion on X-ray examination, and an increase in disc height, a reduction in the degree of listhesis, an increase in segmental lordosis, and an increase in whole lumbar lordosis were significant in both groups (p=.000) compared with before the surgery. Foraminal volume, foraminal width, and foraminal height also significantly increased postoperatively compared with before the operation (p=.000). The height, width, and dimension of resected body were 4.61±1.05 mm, 7.92±1.42 mm, 17.15±4.96 mm(2), respectively, in patients with foraminal stenosis caused by a posterior osteophyte, and 3.88±0.92 mm, 6.8±1.29 mm, and 13.12±2.25 mm(2), respectively, in patients with foraminal sequestrated disc.
  
  
  CONCLUSIONS
  The microscopic anterior foraminal approach provides successful foraminal decompression. Combined with ALIF and PPF, this approach shows a good surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or those with foraminal sequestrated disc herniation.
authors.affiliation: Department of Neurosurgery, Busan Wooridul Spine Hospital, Hubsky WIAA 10F, 158-3 Oncheon 1-dong Dongrae-gu, Busan 607-831, South Korea. Electronic address: pusanwrd@daum.net.
authors.forename: Sang-Ha
authors.initials: SH
authors.lastname: Shin
authors.forename: Won-Gyu
authors.initials: WG
authors.lastname: Choi
authors.forename: Byeong-Wook
authors.initials: BW
authors.lastname: Hwang
authors.forename: Yi-Sheng
authors.initials: YS
authors.lastname: Tsang
authors.forename: Ewy-Ryong
authors.initials: ER
authors.lastname: Chung
authors.forename: Hyeong-Chang
authors.initials: HC
authors.lastname: Lee
authors.forename: Sang-Jin
authors.initials: SJ
authors.lastname: Lee
authors.forename: Sang-Ho
authors.initials: SH
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D001863:Bone Screws; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D020127:Recovery of Function; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000379:methods*; D013168:Spondylolisthesis / Q000601:surgery*; D016896:Treatment Outcome
keywords: Anterior lumbar interbody fusion; Foraminal stenosis; Posterior-lateral osteophyte; Sequestrated disc herniation; Spondylolisthesis